A coroner has criticised doctors for their “gross failure” in not diagnosing a two-year-old girl with sepsis – ruling neglect contributed to her death.

Marcie Tadman was being treated for pneumonia at the Royal United Hospital in Bath when she suffered a fatal cardiac arrest on December 5 2017.

The toddler had been seen by seven doctors who were treating the pneumonia as the main cause of her illness and had not considered sepsis, Avon Coroner’s Court heard.

Coroner Maria Voisin listed a range of failings by the hospital and recorded a conclusion that Marcie died from natural causes contributed to by neglect.

“I consider that putting these basic failures together led to the gross failure to provide or perform any effective medical treatment,” she said.

“I find that the gross failure has caused or significantly contributed to Marcie’s death.”

Ms Voisin also said she was “disturbed” by some of the evidence given by witnesses of the extent of the “miss-remembering by those involved” in Marcie’s care.

Expert Dr Nelly Ninis told the inquest that systemic failures on the children’s ward led to Marcie’s death.

She said Marcie would not have died had staff followed their own guidelines, as well as those from the National Institute for Health and Care Excellence and transferred her to a paediatric intensive care unit.

Marcie’s father James Tadman had taken her to the hospital’s emergency department the previous day because she had a cough, a high temperature and had been vomiting – but the sepsis screening tool was not completed.

Three days before her death, Marcie had been seen by an out-of-hours GP who had diagnosed a viral infection and told her father to give her Calpol.

Dr Ninis said: “There was such as systemic failure here to manage a child with a serious illness. Children with serious illnesses show you where all the failings are because they fall ill so quickly.

“The hospital policies are well written and had they been used they would have been enough, and there were Nice guidelines that were not followed.

“It was so remarkable – the lack of attention to detail – one does have to wonder if this is a common feature in this unit.”

The hearing heard there was not an “ingrained” culture to test for sepsis on the children’s ward.

The little girl was seen by a doctor on the afternoon before her death, but not reviewed again for 11-and-a-half hours.

She was about to be transferred to the intensive care unit when she suffered a fatal cardiac arrest.

He father told the inquest: “I explained to Marcie that everything was okay and they were going to go to another room.

“She looked at me and said, ‘Okay, Daddy’. When the nurse finished giving the fluids Marcie looked at me, took one big breath and she looked straight into my eyes.

“I had hold of her other hand and was stroking it, telling her she was going to be okay, she just seemed to turn off when she exhaled and went limp.”

A post-mortem examination found Marcie, who lived in Bath with her family, had died from a Group A Streptococcus infection with secondary pneumonia.

Speaking afterwards, Marcie’s father spoke of the “hell” his family has gone through since her death.

Marcie died just a few months after her mother Lindsay passed away, having been diagnosed with cancer.

“As you can all appreciate, my family and I have been through hell and no words can adequately describe how we are feeling,” Mr Tadman said.

“We have lost a very beautiful, caring little girl whose smile would light up any room and melt any heart.

“We put our trust in the Royal United Hospital, assuming that our little girl would be getting the very best card but tragically that was not the case.

“The hospital’s own internal investigation has identified a number of failings and these have been described by one expert as ‘systemic’ in nature.”

He added: “We can only hope that lessons have been learnt and that every child that receives treatment at the hospital in the future will be better protected.

“The only crumb of comfort I can take from the impossible situation I find myself facing is that Marcie has been reunited with her Mummy, my wife, who sadly lost her fight against cancer in July 2017.”